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Form of workAdventist Health Bakersfield has served the residents of Kern County with skill and compassion for more than 100 years. Our medical center is a 254-bed acute-care facility that includes key services areas including emergency care, brain and spine, heart care, cancer care, orthopedics, surgical services and robotics, primary care and more. You can also find close-to-home care by visiting the Adventist Health Physicians Network of providers, our three Quest Imaging locations and the Adventist Health AIS Cancer Center - the only comprehensive cancer care center in Kern County with the Commission on Cancer (CoC) accreditation for our program's multidisciplinary approach to treating cancer. The hospital is staffed by more than 645 affiliated physicians, 1,832 associates and more than 250 volunteers.
Adventist Health Bakersfield has been recognized as one of the 'Best Hospitals' by U.S. News & World Report, regionally ranked #1 in overall hospital quality in the Central Valley among 416 hospitals. The rankings place us in the top five percent of hospitals statewide and demonstrates Adventist Health Bakersfield's dedication to quality care for our patients and community. Adventist Health Bakersfield is the only hospital in Kern County to earn an A Hospital Safety Grade by The Leapfrog Group eight times in a row. While this is a great recognition, what it really shows is our unwavering commitment to our patients, community and mission of 'Living God's love by inspiring health, wholeness and hope.'
Job Summary:
Reviews, evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of Clinical Documentation of the patient medical record and ensure it is in compliance with government and other regulations. Works on problems of moderate to diverse scope requiring some interpretation of policies and guidelines. Applies working knowledge of the techniques, principles, theories and concepts to complete routine and non-routine assignments. Runs program(s) with moderate budget/impact.
Job Requirements:
Education and Work Experience:
- Associate's/Technical Degree or equivalent combination of education/related experience: Required
- Bachelor's Degree: Preferred
- Three years' clinical experience: Required
- Two years' Clinical Documentation experience: Required
Licenses/Certifications:
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required within two years after hire
- Current licensed RN, medical provider or equivalent: Required
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
Essential Functions:
- Evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of Clinical Documentation of the patient medical record. Performs coding, working DRG assignment and enters all review activity into tracking software.
- Analyzes and interprets medical records and Clinical Documentation and formulates appropriate physician queries. Performs follow up on incomplete physician queries to obtain an answer while the patient is still in house. Updates "working DRG" as documentation supports, or physician query answer supports a change in the DRG assignment.
- Reviews quality of medical record and communicates when conflicting data are found, the Clinical Documentation Integrity Specialist (CDIS) conveys deficiencies to the department lead for more information to resolve the conflict.
- Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies. Attends ongoing education sessions.
- Acts as a liaison between the medical staff and the coding department. Works collaboratively with physicians and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to all patients. Attends scheduled physician and care management meetings as requested and reviews requested cases prior to the meetings.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
